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Date Archives: 17-Jun-2013

Question: I am asked to transport a patient to the cath lab. The new onset unstable angina patient (who is bradicardic with a lowest rate of 38 and multiple unifocal pvcs) and is only CP free because of the nitro during patch put on by the ER doctor. Does leaving the patch on constitute me giving a medication that is out of my skill set? Since she/he is bradicardic (but has a good pressure) do I have to remove it? Do I have the ability/obligation to remove a treatment started by the attending ER physician? Escort required? Other suggestions?

Answer: Excellent question! In terms of the patient stability and the role of including a possible medical escort, this is a real issue that you must communicate with the sending physician. You should explain your concerns regarding the patient condition; explain the limits of your scope of practice and your ability to intervene if the patient were to deteriorate.

Ultimately, the sending physician is responsible for the welfare of the patient on transport and the role of appropriate medical escorts. However, when situations have arisen in the past, crucial conversations as to the various escorts that may be available to assist you (RT, RN, MD, Ornge) have led to enhanced patient safety on transport. Your supervisor and or the Base Hospital Physician may also be a useful resource if you are confronted with a transport where you feel the patient may benefit from an enhanced scope of practice. The Base Hospital will stand behind you in addressing safety concerns you may have when asked to transfer an unstable patient you feel requires additional medical escorts.

To answer your specific questions, no, transporting a patient with a NTG patch does not constitute you administering a medication that is out of your skill set. In your example, this medication was prescribed by the sending physician and they are the most responsible for the welfare of this patient and the safe administration of this medication.

You do not have to remove the NTG patch because the patient’s vital signs fall out of the parameters whereby you are authorized to administer NTG spray. The attending physicians are not required to follow the same indications and contraindications however are responsible for the safety of their patient. Voicing your concerns and explaining the limits of your scope of practice is an essential communication that should take place and a medical escort may be indicated.

You are not obligated and nor should you discontinue a medication that has been ordered for a patient by an attending physician. Again, if you are concerned about the appropriateness of that medication, you should highlight your concerns in a non-confrontational manner in the interest of patient safety.

Question: I have been hearing a lot lately of BHPs telling PCP crews to give a drug (such as Epi) on a VSA when they call for a TOR. Even after reiterating that they were a PCP/BLS crew there still seemed to be some confusion. In some cases complicating the situation to the point where the misunderstanding seemed to lead to an order to transport as opposed to granting a TOR. Is there a better way to disseminate the differences to the doctors who may be taking the TOR or BHP patch (such as a card distributed to the doctors or a chart posted at the patch phones outlining what PCP crews can do vs. ACP crews)? I am sure it is as frustrating for the doctor taking the patch as it is for the crew trying to explain why they can't do what is being asked. Maybe something like this could help ease the whole process?

Answer: Great question. You are absolutely right, there have been occasions where the BHP have asked paramedic crews to administer medications or perform procedures that are beyond their scope of practice. The Medical Council of the Southwest BH has worked very hard to communicate with the BHP the various Medical Directives that form your practice. It is clear we still have work to do.

We do have copies of the Medical Directives at the patch phone, on our website, we continue to meet and communicate with the BHP as to updates and changes to the scope of practice.

If you have a specific patch or concern where this arises in the future, please let us know. We would be more than willing to follow up with the specific BHP.

Question: You are called to a retirement home for an 85 y/o female for a possible CVA. On arrival you are met by a Nurse Practioner who stated patient is having a stroke. Nurse Practioner also states that patient (who is a retired RN) has talked to her family doctor who agrees with patient's decision of not wanting to go to stroke centre or stroke protocol done. Patient has history of heart. Assessment reveals patient alert, orientated x 3 and meets stroke protocol. Patient wants to be transported to the local hospital for assessment. Does this patient or any patient have the right to refuse transport to a stroke centre?

Answer: What an interesting and fortunately rare event. Most patients are not aware of the specifics of stroke management: alternate destination of transport to a stroke centre and the specific role of thrombolytics. To have a patient who is so aware of the literature as to make a decision to not wish to be transported to a stroke centre would have to be a rare event.

The bottom line is that if you feel the patient has the capacity make their own decisions and has the ability to understand the risks and benefits associated with refusing transport to a stroke centre (where patients have better outcomes not only from the use of thrombolytics but also gain other benefits from specialized stroke care and rehabilitation), then the patient can refuse.

One should also be cautious that alternate destinations may lead this patient to be transported to a facility which may not have the diagnostic equipment required to delineate the underlying etiology of this patient’s condition.

Specifically, the closest hospital may not have a CT scanner, and the patient may be suffering from a different condition other than a CVA. It is quite possible that the closest ED physicican may ultimately request a secondary transport of this patient to a CT capable hospital: not an efficient use of resources if this could have occurred initially. Regardless, once transported to a Stroke Centre, patients can always decline the administration of a thrombolytic yet still gain from the specialized stroke care. This is another benefit of the Stroke Strategy.

Question: With respect to use of an OPA, I have had discussions with coworkers who always will insert one with an unconscious patient. Is this proper? My argument is, even the MOH literature seems to state that 'less invasive' airway management such as positioning, suctioning and constant monitoring of the airway is acceptable. Some common situations of this would be a post-itcal or alcohol intoxication persons. Thanks.

Answer: The concern with an OPA is that a patient may have an impaired level of consciousness however still have an intact gag reflex. Automatically utilizing an OPA – especially for post ictal or alcohol intoxication- may lead to the complications from an OPA such as vomiting, aspiration, and/or laryngospasm.

As the use of the OPA is not a controlled act, we promote adherence to the Basic Life Support Patient Care Standards (BL-PCS) for the use of such airway adjuncts. Great question!